Provider Demographics
NPI:1760219182
Name:BAVA, JACOB GERARD (BA, MED)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:GERARD
Last Name:BAVA
Suffix:
Gender:M
Credentials:BA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13303 TESSON FERRY RD STE 50
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-4062
Mailing Address - Country:US
Mailing Address - Phone:636-379-1779
Mailing Address - Fax:636-634-3496
Practice Address - Street 1:13303 TESSON FERRY RD STE 50
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:636-379-1779
Practice Address - Fax:636-634-3496
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022049314101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health